Palliative Oncology Research Articles

Engaging Oncologists Toward Integrating a Shared Mental Model (SMM) for Palliative Oncology within a Large Academic Oncology Practice (TH341B)

Engaging Oncologists Toward Integrating a Shared Mental Model (SMM) for Palliative Oncology within a Large Academic Oncology Practice (TH341B)

Pediatric Palliative Oncology Patients: Demographics, Treatment and End-of-Life Experiences of a Vulnerable and Understudied Population (TH340D)

Pediatric Palliative Oncology Patients: Demographics, Treatment and End-of-Life Experiences of a Vulnerable and Understudied Population (TH340D)

Pediatric palliative oncology: the state of the science and art of caring for children with cancer.

Pediatric palliative oncology (PPO) is an emerging field that integrates the principles of palliative care early into the illness trajectory of children with cancer. PPO providers work with interdisciplinary clinicians to provide optimal medical and psychosocial care to children with cancer and their families. Ongoing advances in the field of pediatric oncology, including new treatment options for progressive cancers, necessitate the early integration of palliative care tenets including holistic care, high-quality communication, and assessment and management of refractory symptoms. Research in this emerging field has expanded dramatically over the past several years. This review will focus on advancements within several key areas of the field, specifically regarding investigation of the communication needs and preferences of patients and families, exploration of educational initiatives and interventions to teach PPO principles to clinicians, study of patient-reported and parent-reported tools to better assess and manage refractory symptoms, and development of novel models to integrate palliative care within pediatric oncology. Research findings in the field of PPO, concurrent with advances in the treatment of pediatric cancer, may help improve survival and quality of life for children with cancer.

Implementation of Electronic Patient-Reported Outcomes (PRO) in Outpatient Oncology Palliative Medicine (PM) Consults (QI831)

•List at least 3 symptoms screened in an electronic PRO tool.•Describe usability of an electronic PRO tool including the average completion rate and duration for completion of each screen. PROs are an important component of oncology care that allows patients to measure their perceptions of their symptoms, functional status, and well-being. Evidence has demonstrated benefits in survival, quality of life, and symptom control. Systematic collection of PROs in the oncology PM setting, where distress and symptom burden is typically high, benefits both the individual patient care plan and monitoring of population level outcomes. To assess utilization and effectiveness of an electronic PRO screening tool for new outpatient oncology PM patients. The oncology PM clinic implemented a tablet-based PRO screening tool available in English or Spanish with a total of 39 questions including 11 symptom scales (0-10) and four validated screens for anxiety/depression, nutrition, spirituality, and function. Patients were provided the tablet at check-in, and completed results were integrated into the electronic medical record. Average completion time was 8 minutes. The PRO results were reviewed by the PM team during the consult to assist with clinical decision-making and referrals. During the first six months of 2017, 85% (n=151) of new oncology PM patients completed the PRO tool. The average fatigue score (0-10) was 6.6, pain 6.1, and nausea 2.5. Patients ranked depression 1.2 and anxiety 0.9 on a 0-3 scale. Anorexia was reported in 52% (n=78) with 32% reporting weight loss of greater than 13 lbs. Functional deficits were reported in 11% (n=16). Electronic PROs provide an effective way to screen new patients to oncology PM for distress and uncontrolled symptoms during the initial consultation. Results of the screening tool allowed the PM team to address issues that may not have been spontaneously offered by the patient, and triggered referrals to cancer support services (i.e. nutrition, psychotherapy) and other medical specialties.

Genetics in palliative oncology: a missing agenda? A review of the literature and future directions.

In the palliative oncology setting, genetic assessment may not impact on the patient's management but can be of vital importance to their surviving relatives. Despite care of the family being central to the ethos of palliative care, little is known about how hereditary aspects of cancer are addressed in this setting. This review aims to examine current practices, identify practice barriers and determine the genetic information and support needs of patients, family members and health providers. Key databases were systematicallysearched to identify both quantitative and qualitative studies that addressed these aims. Data was extracted and coded using thematic analysis. Eight studies were included for review. Suboptimal genetic practices were identified, with lack of knowledge and poor confidence amongst providers reported as barriers in both qualitative and quantitative studies. Providers expressed concern about the emotional impact of initiating these discussions late in the disease trajectory; however, qualitative interviews amongst palliative patients suggested there may be emotional benefits. All lines of evidence suggest that genetics is currently missing from the palliative agenda, signifying lost opportunities for mutation detection, genetic counselling and appropriate risk management for surviving relatives. There is an urgent need for interventions to improve provider knowledge and awareness of genetic referral pathways and for research into the genetic information and support needs of palliative care patients.

The Role of Palliative Care in Oncology.

Palliative care is a powerful adjunct to oncology that adds distinct value to the physical, mental, and psychosocial well-being of patients living with cancer. Its expanding role and integration with standard oncologic care has proven clinical benefit, as the practice of palliative care can help alleviate symptom burden, enhance illness and prognostic understanding, and improve both the quality of life and overall survival for patients. The primary aim of this review article is to highlight the significant interplay between palliative care and oncology and, in doing so, shed light on the areas for improvement and modern challenges that exist to meet the complex palliative care needs of patients with cancer.

Factors Associated With Attrition in a Multicenter Longitudinal Observational Study of Patients With Advanced Cancer

ContextAttrition is common in longitudinal observational studies in palliative care. Few studies have examined predictors of attrition. ObjectivesTo identify patient characteristics at enrollment associated with attrition in palliative oncology outpatient setting. MethodsIn this longitudinal observational study, advanced cancer patients enrolled in an outpatient multicenter study were assessed at baseline and two to five weeks later. We compared baseline characteristics between patients who returned for follow-up and those who dropped out. ResultsSeven hundred forty-four patients were enrolled from Jordan, Brazil, Chile, Korea, and India. Attrition rate was 33%, with variation among countries (22%–39%; P = 0.023). In univariate analysis, baseline predictors for attrition were cognitive failure (odds ratio [OR] 1.23 per point in Memorial Delirium Assessment Scale; P < 0.01), functional status (OR 1.55 per 10-point decrease in Karnofsky Performance Status; P < 0.01), Edmonton Symptom Assessment Scale [ESAS] physical score (OR 1.03 per point; P < 0.01), ESAS emotional score (OR 1.05 per point; P < 0.01), and shorter duration between cancer diagnosis and palliative care referral in months (OR 0.89 per log; P = 0.028). In multivariate analysis, cognitive failure (OR 1.12 per point; P = 0.007), ESAS physical score (OR 1.18 per point; P = 0.027), functional status (OR 1.35 per 10-point decrease; P < 0.001), and shorter duration from cancer diagnosis (OR 0.86 per log; P = 0.01) remained independent predictors of attrition. ConclusionAdvanced cancer patients with cognitive failure, increased physical symptoms, poorer performance status, and shorter duration from cancer diagnosis were more likely to dropout. These results have implications for research design, patient selection, and data interpretation in longitudinal observational studies.

Implementation of an interdisciplinary care team to create individualized care plans for high risk oncology patients: A model to decrease aggressiveness of care at the end of life and improve cost effectiveness of care.

171 Background: Due to complexity of disease and treatments, oncology patients have among the highest hospitalization rate, especially towards End of Life (EOL). In our cancer institute, just 6% of all discharged patients accounted for &gt;40% of unplanned readmissions, and continue to be highest risk of future admissions, ICU stay, ED visits, overuse of chemotherapy and under use of hospice care. We hypothesized that developing individualized care plans (ICP) for this high-utilization group will provide guidance in the complex care they require to reduce unnecessary and aggressive medical services. Methods: An Interdisciplinary Care Team (ICT) was created consisting of palliative medicine and oncology physicians, social workers, care coordinators, and nurses. On a bimonthly basis, patients with at least two unplanned hospital readmissions over the last 60 days were identified. ICPs were created using a team-based approach with parallel input from patient’s primary outpatient providers. Results: A total of 36 patients, 226 hospitalizations, and 163 ED visits were evaluated over a 6-month period, with an average number of hospitalizations of 1.08 per patient month (ppm). After implementation of ICP, hospitalizations decreased to 0.23 ppm, with an average length of stay decrease from 7.17 to 4.06 days per admission. Average ED visits decreased from 0.58 to 0.34 ppm, and the average number of unplanned readmissions decreased from 0.43 to 0.13 ppm. Of the 10 patients expired since creation of ICP, 8 utilized hospice care, while 2 patients died in an ICU. Average time to death from creation of ICP was 72 days among this cohort, while time to death from last exposure to chemotherapy was 58 days. Conclusions: Creation of individualized care plans for high-utilizing cancer patients decreased number of hospitalizations, ED visits, unplanned readmissions, and length of stay. A dedicated focus from a team of experts, beyond disease biology, on a unique patient situation may result in improved patient experience with decreased aggressiveness of care at EOL and overall resource utilization.

Evaluation of an NP-based model of palliative care delivery within an oncology clinic.

163 Background: We initiated a nurse practitioner (NP)-based model of palliative care delivery embedded within an oncology clinic guided by a shared mental model (SMM) between palliative care, oncology, and psychosocial oncology clinicians in order to foster best practice collaboration and closed-loop communication between teams. These data represent processes and outcomes three years after initial implementation of the program. Methods: We evaluated program growth as well as advance care planning, hospice use, and utilization in patients with advanced cancer seen by the palliative care NP compared to patients receiving usual care from March 2014 to March 2017 at University-based oncology clinics. We developed a palliative care quality improvement tool integrating administrative and clinical data from multiple sources, including the electronic health record (EHR) and external hospices, using progressive methods of pulling data, such as natural language processing, in order to identify patients with advanced cancer and key process and end of life utilization measures. We used chi square tests to compare care received by the two groups. Results: There was good adoption of the intervention. The number of participating oncologists increased from 2 to 5 and the palliative care NP shifted from part-time to full-time after the first 1.5 years of implementation. Patients enrolled in the NP-based model of palliative care delivery were more likely to have a documented goals of care conversation (74.6% v. 9%, p &lt; 0.01), to be referred for additional psychosocial support (52.5% v. 30.9%, p &lt; 0.01), and to complete physician orders for life sustaining treatment (POLST) (20.3% v. 4.5%, p &lt; 0.01). There was no statistically significant difference in advance directive completion (28.8% v. 23.5%). Among decedents, patients enrolled in the NP-based model were more likely to be enrolled in hospice (50.5% v. 29.1%, p &lt; 0.01). There were non-statistically significant trends toward less hospital (4.6 days v. 5.6 days) and ICU use (1.0 day vs. 1.3 days) in the last 30 days of life. Conclusions: An NP-model of palliative care delivery within an oncology clinic led to important improvements in key palliative care processes and outcomes.

Propensity score matched analysis of a palliative radiation oncology consult service’s impact on length of stay and total costs during hospitalization.

162 Background: The Palliative Radiation Oncology Consult Service (PROC) was a clinical service model developed in 2013 at Mount Sinai Hospital to provide individualized, goal-directed treatment to advanced cancer patients requiring palliative radiation therapy (PRT). We assessed its impact on length of stay (LOS) and total costs incurred during a hospitalization among patients who underwent PRT for symptomatic bone metastases while in the hospital. Methods: In our observational cohort study, we identified patients who underwent their first PRT course for bone metastases during a hospitalization between 2/2010 and 12/2016. Total costs (direct and indirect costs) during the hospitalization were extracted from the institution’s cost accounting system. Propensity score matching (PSM) was performed against age, Charlson comorbidity index (CCI), gender, race, primary cancer, and health insurance status. Balance across groups was verified by standardized differences before and after PSM. Average treatment effects (ATE) of hospital costs and LOS were calculated from generalized linear models with a γ distribution and log link adjusted by propensity score weights. PRT patients treated before 2013 (before PROC was established) were compared to those treated after 2013 (after PROC was established). Results: In total, 181 patients were included, with 76 treated before and 105 treated after PROC. Before propensity score matching, patients treated prior to PROC’s establishment had a median total hospital cost of $72,787 (range, $5,981-$324,652) and a median LOS of 28 days (range, 2-105); whereas patients treated after PROC had a median total hospital cost of $49,950 ($7,585-$620,943) and a median LOS of 19 days (2-139). After matching, patients had an ATE of -$16,877 total hospital cost (95% CI [-33,250,-504], p = 0.043) and -8.5 days in LOS (95% CI [-13.9,-3.2], p = 0.002). Conclusions: PROC, a clinical service model that integrated principles of palliative care practice within radiation delivery, led to substantial cost-savings and shorter lengths of stay for advanced cancer patients requiring PRT for bone metastases during a hospitalization.

Engaging oncologists toward integrating a shared mental model for palliative oncology within a large academic oncology practice.

105 Background: We aimed to engage oncologists to disseminate a successful pilot-tested shared mental model (SMM) for the integration of early advance care planning (ACP) and identification of palliative care (PC) needs across a health system’s oncologic practice. Methods: Our Oncology Communication Collaborative Team (OCCT) had oncology leadership support and included a multidisciplinary team representing leaders in oncology, ACP, PC, psycho-social oncology and quality. To communicate the SMM developed by our team, the OCCT developed an interactive Saturday session (1-hr didactic, 3-hr small group role-play) that focused on early ACP and the cognitive and emotional aspects of communication. Before and after the training, we asked participants to rate their ability to communicate with patients as well as their readiness, self-efficacy, and need for help to improve communication regarding prognosis, ACP, end of life care and symptom management using a previously validated survey. We computed means and compared matched pairs of pre and post surveys using a paired t-test. We also surveyed participants about whether they would recommend the course to others and planned changes to practice. Results: All but one oncologist (52/53), 3/4 invited fellows, and 12/14 oncology nurse practitioners participated and 90% of attendees completed pre and post surveys. Participants rated their communication ability higher (6.7 v. 7.6, p &lt; 0.01) on a 10-point scale after the training. Readiness to improve communication in this domain (9.1 v. 9.2, p = 0.35) was similar before and after the training. Self-efficacy (1.5 v. 1.5, p = 0.70) and needing help to improve (1.6 v. 1.7, p = 0.37) were rated highly (1 = A lot and 4 = Not at all) but did not change with training. All but one participant reported they would recommend the course to others and free text responses about changes they planned to make to their practice based on the training included: having earlier ACP discussions, focusing on patient goals/priorities and asking open-ended questions. Conclusions: Conducting a training to disseminate a SMM of oncology and PC is feasible, valuable, and can be the first step for partnered continuous quality improvement.

Home Parenteral Nutrition (HPN) in palliative oncology patients: A UK single centre case series

Home Parenteral Nutrition (HPN) in palliative oncology patients: A UK single centre case series

The Social Representations of Medical Clinic Nurses on Oncology Palliative Care: a Procedural Approach

The Social Representations of Medical Clinic Nurses on Oncology Palliative Care: a Procedural Approach

Developing a Palliative Radiation Oncology Service Line: The Integration of Advance Care Planning in Subspecialty Oncologic Care

ABSTRACTWithin radiation oncology, there is often minimal attention on radiotherapy with palliative benefits due to the overlying focus on curative treatments. Historically at the University of Pennsylvania, advanced-stage patients are cared for by cancer site-specific teams rather than a more rapid treatment service model that focuses on patients’ symptom needs and larger clinical issues within a palliative framework. Thus, the University of Pennsylvania created a designated palliative radiation oncology team to focus on the complex medical and relational issues of metastatic cancer patients. Social workers play a critical role in patient and family conversations about advance directives, care needs, and end-of-life goals and fears as treatment regimens and outcomes continue to unfold. The palliative radiation oncology social worker developed and instituted a new, formalized assessment tool called the “palliative radiation oncology psychosocial care plan” in the electronic medical record. A retrospective analysis of 26 palliative radiation oncology patients under treatment between February and August 2016 was conducted. Of these patients treated with palliative radiation, 19% completed an advance directive after the social work intervention. This model highlights advance care planning as a best practice and encourages end-of-life discussions as a routine part of the oncology workflow.

Informal Caregiver Quality of Life in a Palliative Oncology Population

Many patients with advanced cancer receive primary supports from informal caregivers (IC). As patient health deteriorates, IC assume increasing responsibility, often accompanied by distress. We investigated the quality of life (QOL) of IC of patients referred to a palliative radiotherapy (PRT) program. IC accompanying patients to a dedicated PRT clinic completed a survey based on the validated Caregiver Quality of Life Index-Cancer (CQOLC). Demographics, burden, and engagement in support services were evaluated. Summary statistics were calculated, and parameters were assessed for association with CQOLC scores by a generalized linear model. Two hundred one surveys were analyzed representing 197 unique patients. The mean age was 68.3 years, with predominantly lung (25.0%) and prostate (19.3%) malignancies. 24.4% had been in hospital/long-term care within the previous 7 days. IC were 60.8% female, and 60.6% were the patient’s spouse. 69.5% lived with the patient and 38.3% were additionally employed. IC spent a daily mean of 6.6 h (SD 7) assisting with instrumental (72.5%) and basic (37.5%) activities of daily living. Mean CQOLC score was 82.1/140 (SD 20). 63.8% of IC had previously accessed support service(s), most commonly home care (37.2%) and pharmacy (29.1%). 55.9% indicated interest in services not yet accessed. Multivariate analysis revealed additional employment, cohabitation, poor patient performance status, and interest in accessing more support services significantly correlated with higher IC burden. Employing the CQOLC to screen IC of patients referred to a PRT program permits early identification of vulnerable IC to facilitate linkage with appropriate supports.

LBA54_PR - Proactive referral to palliative care: Model of a new integrated palliative care and oncology service

LBA54_PR - Proactive referral to palliative care: Model of a new integrated palliative care and oncology service

1565P - Association between systemic inflammation and symptoms in advanced cancer patients

Background: There is growing evidence relating inflammation as a prognostic factor in cancer patients. Previous reports have found a small but significant association between systemic inflammation and symptoms in advanced cancer patients. The aim of this study was to analyse the relationship between systemic inflammatory response markers with the symptoms and performance status of advanced cancer patients that have been admitted to an Acute Palliative Care Unit (PCU). Methods: We conducted an observational study including all cancer patients admitted in the PCU between January 2012 and April 2015. We performed a correlation analysis (spearman’s rho) between serum C-reactive-protein (CRP), the modified Glasgow Prognostic Score (mGPS) and Neutrophil-to Lymphocyte Ratio (NLR) with patients symptoms recorded as the Edmonton Symptom Assessment Sytem (ESAS) and performance status recorded as Eastern Cooperative Oncology Group (ECOG), Barthel Index and Palliative Performance Scale (PPS). All data were collected within the first two days of admission. Results: Data of 951 patients were available. The median survival was 17 days. CRP was significantly correlated with ECOG (ρ:0.180, P:0.000), dyspnoea (ρ:0.079, p:0.019), fatigue (ρ:0.162, p < 0.001), anorexia (ρ: 0.103, p:0.002), somnolence (ρ:0.096, p.0.009), wellbeing (ρ:0.012, p < 0.001), Barthel (ρ:-0.178, p < 0.001) and PPS (ρ:0.173, p < 0.001). In relation to mGPS, a significant correlation was found with ECOG (0.116, p:0.001), fatigue (ρ:0.184, p < 0.001), anorexia (ρ:0.107, p.0.003), somnolence (ρ:0.080, p.037), Barthel (ρ:-0.127, p < 0.001) and PPS (ρ:-0.125, p < 0.001). Finally, NLR was significantly correlated with ECOG (ρ:0.112, p0.001), dyspnoea (ρ:0.117, p < 0.001), fatigue (ρ:0.107, p:0.002), Barthel (ρ:-0.115, p < 0.001) and PPS (ρ:-0.100, p:0.002). Conclusions: There is a small but significant correlation between systemic inflammation and symptoms. Further studies are needed to confirm the results and to test this relation in earlier phases of the disease. Legal entity responsible for the study: Hospital Universitario La Paz Funding: None Disclosure: All authors have declared no conflicts of interest.

Pilot Study of a Palliative Care and Medical Oncology Co-Rounding Model for Advanced Cancer Inpatients in a Tertiary Hospital in Singapore.

Our aim was to obtain initial estimates of the effect of a palliative care and medical oncology co-rounding model on hospital length of stay, proportion of patients reviewed by specialist palliative care (SPC), and proportion of patients who were readmitted within 7 and 30 days of hospital discharge. Earlier timing of palliative care improves patient outcomes, but current consultative models of palliative care service delivery are not feasible for widespread implementation. We conducted a pilot pre-post intervention study of a palliative care and medical oncology co-rounding model of care in the inpatient hospital setting. All patients admitted under the care of an inpatient oncology team during the study period were included. Hospital length of stay, proportion of patients reviewed by SPC, and readmission data were retrieved from the electronic administrative database. There were 595 unique patients (352 in the "consultative" group and 243 in the "co-rounding" group). There was no significant difference in the proportion of patients who were reviewed by a SPC physician (consultative model 21.02% vs. co-rounding model 25.10%, p = 0.243). The hospital length of stay was shorter for the co-rounding group (median 3 days, interquartile range 2-7 days) compared with the consultative group (median 4 days, interquartile range 2-7 days) (p = 0.025). There was no significant difference in proportion of patients readmitted within 30 days of hospital discharge (consultative model 29.78% vs. co-rounding model 28.90%, p = 0.773). In our target population, the co-rounding model was associated with a shorter hospital length of stay.

PRADO: A Palliative Care Model for Every Radiation Oncology Practice

During the past few years, large academic radiation oncology programs have uncovered a significant gap in providing palliative care to hospitalized cancer patients. The renowned SPRO (Supportive and Palliative Radiation Oncology) service at Brigham and Women's Hospital ( 1 Tseng Y.D. Krishnan M.S. Jones J.A. et al. Supportive and palliative radiation oncology service: Impact of a dedicated service on palliative cancer care. Pract Radiat Oncol. 2014; 4: 247-253 Google Scholar ) has charted the waters since 2011. Similar programs have begun, including, but not limited to, inPROV (Inpatient Palliative Radiation Oncology Service at Vanderbilt) ( 2 Stavas M.J. Pagan J.D. Varma S. et al. Building a palliative radiation oncology program: From bedside to B.E.D. Pract Radiat Oncol. 2017; 7: 203-208 Google Scholar ) and SOPR (Supportive Oncology and Palliative Radiotherapy at the University of Pennsylvania), which have provided a tremendous benefit to patients, improvements in physician satisfaction, and increases in patient volumes. These academic programs have also incorporated closer follow-up protocols for a subset of patients with metastatic disease, who have a greater risk of requiring additional radiation treatment (RT), such as patients who have received a single fraction of palliative RT (8 Gy × 1) or patients with central nervous system involvement or oligometastatic disease.

Cuidados paliativos oncológicos em um serviço público de atenção domiciliar

Objetivo: Identificar o perfil dos pacientes com câncer e em cuidados paliativos e suas demandas referentes ao atendimento multidisciplinar existente em um Serviço de Atenção Domiciliar. Métodos: Estudo transversal com coleta de dados secundários dos pacientes oncológicos em cuidados paliativos atendidos pelo Programa de Atenção Domiciliar do Grupo Hospitalar Conceição, no ano de 2013. Aprovado pelo Comitê de Ética e Pesquisa sob o número 13.203. Resultados: Foram acompanhados 63 pacientes com diagnóstico de neoplasia. Dentre esses, 71,5% (n=45) estavam em cuidados paliativos. As medianas do tempo de acompanhamento dos pacientes foram de 22 (3-146) dias e do número de visitas realizadas pela equipe foi 6 (1-34). Além das visitas semanais realizadas pelas equipes, os pacientes receberam assistência de nutricionista, fisioterapeuta e assistente social. Considerando as 45 internações, os principais cuidados foram controle da dor, curativos em feridas, controle glicêmico, e antibioticoterapia endovenosa. A principal intercorrência clínica foi a repassagem de cateter nasoenteral (n=5). A alta em condições estáveis de saúde ocorreu em 10 pacientes. Conclusão: O presente estudo permitiu a identificação das principais demandas dos pacientes em cuidados paliativos oncológicos atendidos por um serviço de Atenção Domiciliar. Observa-se na prática deste serviço que a maioria dos pacientes apresentou necessidade de cuidados complexos, mas possíveis de serem realizados no domicílio pela equipe de saúde e/ou cuidador capacitado.